No increased risk of perforation during colonoscopy in patients undergoing Nurse Administered Propofol Sedation

Abstract

Objective. Nurse Administered Propofol Sedation (NAPS) contributes to a deeper sedation of the patients, making them unable to respond to pain and an increased incidence of perforations has been speculated. The objective of this study was to evaluate the risk of perforations during colonoscopies performed with either NAPS or conventional sedation regimes. Material and methods. Data were retrospectively retracted from medical journals from 1 January 2007 to 31 December 2011. All journals were examined and cross-referenced to reveal any perforations. We analyzed all colonoscopies in regard to nature of the procedure (diagnostic vs therapeutic), experience of the endoscopist and ASA-classification of the patients. Results. A total of 6371 colonoscopies were performed, of which 3155 were performed under propofol sedation. There were 16 perforations (0.25%); 10 of these performed during NAPS and 6 during conventional colonoscopy (p = 0.454, OR: 1.7 (95% CI: 0.6–5.7)). There were 4874 diagnostic and 1497 therapeutic colonoscopies, with a majority of the perforations (94%) occurring during a diagnostic procedure (p = 0.389). No statistically difference was found in the incidence of perforations caused by an experienced or less experienced endoscopist (p = 0.589). Conclusion. The risk of colonic perforations during colonoscopy was not found to be significantly higher in patients undergoing NAPS compared to patients undergoing conventional sedation, although a tendency may exist. Furthermore, we found no correlation to neither experience of the endoscopist, nature of the procedure nor sex of the patients. Larger and prospective studies are needed to further evaluate on this subject.     

Prevalence of postoperative delirium with different combinations of intraoperative general anesthetic agents in patients undergoing cardiac surgery: A retrospective propensity-score-matched study

Postoperative delirium (PD) remains an issue in cardiac surgery despite the constant efforts to reduce its incidence. In this retrospective study, the incidence of PD was evaluated in patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) according to different primary anesthetic agents: sevoflurane and dexmedetomidine- versus propofol-based anesthesia.A total of 534 patients who underwent heart-valve surgery or coronary artery bypass graft surgery with CPB between January 2012 and August 2017 were divided into 2 groups according to the main anesthetic agent: sevoflurane with dexmedetomidine (sevo-dex group, n = 340) and propofol (propofol group, n = 194). The incidence of PD was evaluated as the primary outcome. Patient-, surgery-, and anesthesia-related factors and postoperative complications were investigated as secondary outcomes. To reduce the risk of confounding effects between the 2 groups, 194 patients were selected from the sevo-dex group after propensity-score matching.After propensity-score matching, the incidence of PD was not significantly different between the sevo-dex (6.2%) and propofol (10.8%) groups (P = .136). In comparisons of the incidence of each type of PD, only hyperactive PD occurred significantly less frequently in the sevo-dex group (P = .021). Older age, lower preoperative albumin levels, and emergency surgery were significant risk factors for PD.The overall incidence of PD after cardiac surgery with CPB did not differ between patients receiving sevoflurane and dexmedetomidine-based versus propofol-based anesthesia. Only hyperactive PD occurred less frequently in patients receiving sevoflurane and dexmedetomidine-based anesthesia.     

他汀类调节血脂药在心血管外科中的应用

近来许多研究表明他汀类调节血脂药除降脂的作用外还具有良好的心血管保护作用 ,本文就其作用机理及其在心血管外科中的应用做一综述。     

心血管外科术后意识障碍和急性心血管事件的病因分析及治疗体会

目的:探讨心血管外科术后意识障碍和急性心血管事件患者的致病因素、疾病经过和相关并发症的治疗。方法:回顾性分析2010-01至2011-02间,39例心血管外科术后早期严重意识障碍的患者,观察分析本组患者的病种与手术方式,术者与手术例数分布,以及术后呼吸机辅助时间和特殊治疗经过等指标。结果:39例患者中,有11例在术后早期出现意识障碍伴谵妄躁动,其中2例患者合并典型的急性心血管事件。与39例患者相关的18位主刀术者中,单个主刀术者完成的手术例数从1例至6例不等。其中在9位主刀术者完成的9例(每人1例)患者中,术后早期有5例出现意识障碍伴谵妄躁动和1例急性心血管事件,而1位主刀术者完成的6例患者中,术后早期仅1例出现意识障碍伴谵妄躁动。全组患者经过镇静、脱水和中枢神经代谢支持等综合治疗,均痊愈。结论:心血管外科术后因脑血管和冠状动脉气栓导致的意识障碍和急性心血管事件应予以重视和明确诊断,以利于预防和减少此类并发症的发生。手术过程中对排除心室腔和大血管内残余气体的重视程度,必要的监测和引导设备,手术技巧和规范操作等因素与术后气栓密切相关。气栓的量和所累及脏器功能损害程度直接影响患者的疾病过程和预后。     

右美托咪定与丙泊酚用于ICU连枷胸合并急性肺损伤患者镇静的效果比较

目的比较右美托咪定与丙泊酚对连枷胸合并肺损伤患者镇静的临床效果。方法选择潍坊市人民医院重症医学科(ICU)2010年9月—2011年8月连枷胸合并肺损伤需要行机械通气的患者30例,随机分为右美托咪定组和丙泊酚组,各15例。右美托咪定组:给予右美托咪定负荷量1μg.kg-1.d-1经静脉泵注射20min,维持剂量0.2～0.7μg.kg-1.d-1支持。丙泊酚组:首先静脉注射1mg/kg丙泊酚进行镇静诱导,维持剂量为0.5～4.0 mg.kg-1.h-1。比较两组患者的心率、平均动脉压(MAP)、芬太尼使用剂量、脱机时间,住ICU时间。结果右美托咪定组在治疗后6、24h时的心率和MAP与丙泊酚组比较,差异均有统计学意义(P<0.05);两组患者在48h的心率和MAP比较,差异无统计学意义(P>0.05)。两组患者脱机时间、住ICU时间和芬太尼使用剂量比较,差异均有统计学意义(P<0.05)。结论右美托咪定应用于连枷胸合并急性肺损伤患者镇静安全、有效,能减少降压药物及芬太尼的用量,并能缩短机械通气时间及住ICU时间。     

Intermittent manually controlled versus continuous infusion of propofol for deep sedation during interventional endoscopy: A prospective randomized trial

Abstract

Introduction. Beside the traditional, intermittent bolus application of propofol, continuous propofol infusion via infusion pump is an alternative procedure for deep sedation during long-lasting interventional endoscopy. However, up to now, there are no randomized comparisons for gastrointestinal endoscopy. Methods. One hundred patients (ERCP: n = 60, EUS: n = 40) were randomly assigned to receive intermittent bolus application (“bolus group”) or continuous infusion (“perfusor group”) of propofol sedation after induction with 3 mg midazolam for deep sedation. Patients in the bolus group received an initial propofol dose according to body weight (bw <70 kg: 40 mg; bw ≥70 kg 60 mg). In the perfusor group, bw-adapted, continuous propofol infusion (6 mg/kg) via the Injectomat 2000 MC (Fresenius-Kabi) was administered after an initial bolus of 1 mg/kg. Vital signs, dose of propofol, patient cooperation (VAS 1–10), sedation depth, and the recovery time as well as the quality of recovery were evaluated. Results. Total propofol dose in the bolus group 305 ± 155 mg (100–570 mg) and in the perfusor group 343 ± 123 mg (126–590 mg, p = 0.5) were comparable. Oxygen saturation below 90% was seen in four patients of each group, with no need for assisted ventilation. Arterial blood pressure <90 mmHg was documented in two patients in the bolus group and seven patients in the perfusor group (p = 0.16). Patients' cooperation was rated as good in both groups (bolus group, 9.1 ± 0.9; perfusor group, 8.9 ± 1; p = 0.17). Recovery time was significantly shorter in the bolus group compared with the perfusor group (19 ± 5 versus 23 ± 6 min, p < 0.001) whereas the quality of recovery was nearly identical in both groups. Conclusion. Both sedation regimens allow nearly identical good controllability of propofol sedation. However, recovery time was significantly slower and hypotension was tended to occur more often in the perfusor group.     

Dexmedetomidine effect on delirium in elderly patients undergoing general anesthesia: A protocol for systematic review and meta-analysis

Background:Delirium is a common postoperative complication. Many studies have found that dexmedetomidine is associated with a reduced incidence of postoperative delirium (POD). This meta-analysis aimed to analyze the effects of dexmedetomidine on POD incidence among elderly patients undergoing general anesthesia.Methods:We searched 4 electronic databases (i.e., Pubmed, Embase, Cochrane, and Web of Science) from inception to November 30, 2020, for randomized controlled trials that evaluated the effects of dexmedetomidine in preventing the occurrence of POD in elderly patients (aged ≥60 years). The study protocol was registered in PROSPERO (CRD42020192114).Results:14 studies with 4173 patients showed that dexmedetomidine was significantly associated with a decreased POD incidence among elderly patients (relative risk [RR] = 0.58; 95% confidence interval [CI] = 0.44–0.76). The incidence of POD was significantly reduced in the noncardiac surgery group (RR 0.51; 95% CI 0.37–0.72), when dexmedetomidine was applied during the postoperative period (RR = 0.53; 95% CI = 0.40–0.70), and in patients received low-doses (RR = 0.54; 95% CI = 0.34–0.87) and normal-doses (RR = 0.59; 95% CI = 0.42–0.83). There were no significant differences in POD incidence in the cardiac surgery group (RR = 0.71; 95% CI = 0.45–1.11), and when dexmedetomidine was applied during the intra- (RR = 0.55; 95% CI = 0.29–1.01) or perioperative period (RR = 0.95; 95% CI = 0.64–1.40).Conclusions:Our meta-analysis suggests that dexmedetomidine may significantly reduce POD incidence in elderly noncardiac surgery patients and when applied during the postoperative period, in addition, both low- and normal-doses of dexmedetomidine may reduce POD incidence. However, its use in cardiac surgery patients and during the intra- or perioperative period may have no significant effects on POD incidence.     

Computerized Algorithms: Use of a Computerized Intravenous Insulin Algorithm within a Nurse-Directed Protocol for Patients Undergoing Cardiovascular Surgery

Background

Several studies have shown the benefits of tight glycemic control in the intensive care unit. A large hospital became concerned about certain deficiencies in the management of glucose control in conjunction with cardiovascular surgery. A multidisciplinary steering committee was formed, which implemented a glycemic protocol, the subject of this study.

Methods

The glycemic protocol is a perioperative, nurse-directed program that incorporates the computerized intravenous (IV) insulin algorithm, Glucommander. Upon admission, hemoglobin A1c and blood glucose (BG) were tested, and patients were screened for previously diagnosed diabetes. This information was used to determine if preoperative insulin will be used, if the patient will be transitioned post-IV to subcutaneous (SC) basal-bolus insulin, and if insulin will be prescribed on discharge. IV insulin was initiated perioperatively in known diabetes cases or if one BG value >140 mg/dl or two BG values >110 mg/dl within 24 hours before or during surgery. The target range was 90 to 120 mg/dl.

Results

In the 9 months after protocol implementation, 93% of the patients had no BG value >200 mg/dl during the first 48 hours postoperatively. In the 6 months of study data, there were 457 patients. The mean time to target range was 3.0 hours. The mean IV insulin run time was 37 hours. The mean BG value was 107 mg/dl. Only 2% of patients had transient BG <50 mg/dl, and no BG values were <40 mg/dl. Of the patients, 52% were transitioned to SC basal-bolus, and 26% were discharged on insulin.

Conclusions

The Glucommander earned high respect from the nurses for the way it scheduled BG tests and eliminated the calculation time and calculation errors associated with manual methods. The protocol was highly effective in normalizing glucose without hypoglycemia. The multidisciplinary steering committee proved to be a good approach to implementing a glycemic protocol.     

Acute Kidney Injury after Cardiovascular Surgery: An Overview

Acute kidney injury is a complication of open-heart surgery that carries a poor prognosis. Studies have shown that postoperative renal function deterioration in cardiovascular surgery patients increases in-hospital mortality and adversely affects long-term survival. Identifying individuals at risk for developing AKI and aggressive early intervention is extremely important to optimize outcomes. This paper provides an overview of the etiology, prognostic markers, risk factors, and prevention of AKI and treatments that may favorably affect outcomes.     

Sedation with a 1:1 mixture of etomidate and propofol for gastroscopy in hypertensive elderly patients

We hypothesized that the combined use of etomidate and propofol for endoscopic sedation in elderly hypertensive patients could reduce adverse reactions while providing ideal sedation. To validate our hypothesis, we conducted a prospective, randomized, controlled, double-blinded study. A total of 360 elderly hypertensive patients scheduled for gastroscopy at our hospital were enrolled in the study, of whom 328 completed the trial. The patients were randomly assigned to one of three groups: the propofol group (group P), the etomidate group (group E), or the propofol-etomidate combination group (mixed at a ratio of 1:1, group PE). We collected and analyzed the cardiopulmonary effects and side effects in each group. Regardless of the sedation drug used, the systolic blood pressure, mean blood pressure, and heart rate of involved patients were significantly affected. Oxygen desaturation and injection pain were more common in group P compared to groups E (33.6% vs. 14.8%, 31.8% vs. 2.7%, both P < 0.01) and group PE (33.6% vs. 13.6%, 31.8% vs. 6.4%, both P < 0.01). The incidence of myoclonus in the PE group was lower than that in the E group (10.9% vs. 61.2%, P < 0.01). Our results indeed demonstrated that the combined use of etomidate and propofol appeared to maintain cardiopulmonary stability with minimal side effects in older hypertensive patients scheduled for gastroscopy, which further implied that this sedation strategy could be a safe and pain-free option for managing patients undergoing gastroscopy, particularly those at a higher risk of adverse cardiovascular events.     

Abdominal Fat Suspension Device for Maintaining Normal Cardiorespiratory Function in Patients Undergoing Conscious Sedation during Surgery: A Feasibility Study

Obese patients undergoing conscious-sedation surgery have increased perioperative morbidity because their excess abdominal tissue limits diaphragmatic excursion. We describe a simple device that might help attenuate this risk. We created a noninvasive suction device for abdominal suspension. By lifting the burden of excess weight, this device should decrease respiratory effort. To test the feasibility of excess weight removal in relieving cardiac stress, we tested 22 supine, healthy, normal-weight subjects by measuring their heart rates with and without a 13-kg tissue model on their abdomen to simulate excess weight. There was no significant difference in blood oxygen saturation before and after weight removal (P=0.318). However, the decrease in heart rate was significant (P <0.0001; paired 2-sample, one-tailed t test), which implies decreased respiratory effort. This result suggests the possibility that abdominal mass suspension in obese patients is associated with decreased respiratory effort.